Who counts as a spouse under your group health plan is your decision, not the ACA’s.

Federal law does not require employers to cover spouses, so the plan document sets the rules. This guide covers eligibility, surcharges, marriage and divorce changes, and COBRA.

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How The Plan Defines A Spouse.

Every spouse rule starts with the plan document and the carrier contract. They say who is eligible, what proof is needed and when coverage ends. Most plans define an eligible spouse as the employee’s legally married spouse, and many add conditions such as a verification step or an exclusion when the spouse can get coverage through their own employer.

The definition matters because it controls enrollment, claims and audits. If the plan document says one thing, the carrier contract another and the enrollment guide a third, you have a dispute waiting for the first claim that tests the difference. Read all three side by side before renewal, and make the employee-facing wording match the controlling document. Note too whether the plan covers only legal spouses or also another category, such as domestic partners, because that is a separate eligibility decision with its own paperwork.

Surcharges And Carve-Outs.

A spousal surcharge adds a monthly charge to the employee’s contribution when the spouse is enrolled even though the spouse has access to coverage through their own employer. A carve-out goes further and excludes those spouses from the plan altogether. Both are design choices, not requirements, and some employers pair them with a credit instead of a charge for spouses who stay on their own plan.

Whatever you pick, apply it the same way to every employee it covers, write it into the plan document and repeat it in open enrollment materials. Decide in advance what proof you will ask for, who reviews it and what happens when an employee does not respond by the deadline. A rule that staff apply differently from one case to the next is the usual source of complaints. Whether a particular design is allowed in your situation is a legal question this page does not answer, so check it with your attorney before adopting or changing one. Our calculator shows the dollar effect on your own census.

Marriage, Divorce And Special Enrollment.

Under the cafeteria plan rules, 26 CFR 1.125-4(c)(2) lists events that can justify a mid-year election change. They include marriage, divorce, legal separation, annulment, the death of a spouse, and a change in the employment of the employee or spouse. Under (c)(3), the change must be consistent with the event. After a divorce or a death, for example, dropping coverage for other people generally does not fit. Your written Section 125 plan should say which of these changes it permits.

Separately, HIPAA special enrollment, 29 CFR 2590.701-6, applies where a plan offers spouse coverage. A person who becomes the employee’s spouse by marriage, and a spouse or employee who loses other coverage, can ask to enroll. The plan must give at least 30 days to ask, and coverage must start no later than the first day of the first month after the plan receives the request. Plans may allow more time or an earlier start, so check your own terms.

When A Spouse Loses Coverage.

Under 29 U.S.C. 1163, the divorce or legal separation of the covered employee from the employee’s spouse is a COBRA qualifying event, as is the death of the covered employee. A spouse who loses coverage because of either event may be able to elect continuation coverage if COBRA applies to your plan. The plan’s terms and the notice deadlines then control the timing, which is why divorce is the event that most often gets missed: the employee is the one who knows about it, and the plan only hears if someone tells it.

Build the reporting step into your enrollment materials, and keep dated records of every notice you send.